Provider Demographics
NPI:1922269570
Name:BLOUNT, KEISHA J (MA,LCAS,CSI)
Entity Type:Individual
Prefix:MS
First Name:KEISHA
Middle Name:J
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:MA,LCAS,CSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 EXECUTIVE CENTER DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8869
Mailing Address - Country:US
Mailing Address - Phone:704-227-0605
Mailing Address - Fax:
Practice Address - Street 1:1800 MARTIN LUTHER KING PKWY STE 102
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-3500
Practice Address - Country:US
Practice Address - Phone:919-490-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1095101YA0400X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)